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Fara Bender DMD Pediatric Dentistry 6169 Jog Road Suite B-5 Lake Worth FL 33467 Telephone 561 433-5544 Fax 561 433-4440 Get Acquainted Questionnaire Health History Form Date Patient Date of Birth / / Name child would like to be called Age y m Gender M F Weight lb. List Medication s Dosage/Frequency Treatment for Date Started Does this child have or has this child ever had any of the following conditions N Drug reactions Latex allergy Environmental/Seasonal allergies Asthma Breathing...
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